MCH Student:

Kara Ulmen

Date of Defense:

October 5, 2018

Abstract:

Introduction 

In the United States, well-child visits allow providers, families, and caregivers to assess a child’s health and development. To ensure individuals on Medicaid receive periodic and age-appropriate care, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides children and adolescents comprehensive, preventive screening and treatment services (Medicaid.gov). In 2015, Wyoming ranked 44^th in the nation for well-visits for Medicaid users under 20 (U.S. News, 2015). Low rates of well-visits may indicate that infants, children, and adolescents are not being screened at appropriate intervals and may receive delayed diagnosis, vaccinations, and treatment. Low rates may also indicate that providers are providing these services, but their coding practices do not capture them as EPSDT. To address this issue, Wyoming Medicaid adopted the American Academy of Pediatrics’ Bright Futures Guidelines, 4^th Edition as their coding standard of care. The guidelines are intended for healthcare providers that see patients from birth to age twenty-one and help ensure each patient receives comprehensive, age-appropriate services for better health outcomes. The overall goal of the field experience was to provide data-informed recommendations on how to best implement the guidelines in the state of Wyoming.

Experience

The goal of the project was completed by the following objectives:

1. Identify relevant preliminary data and key stakeholders for qualitative data collection, and complete design of interview and survey questions. Preliminary data was referenced from the 2010 United States Government Census, U.S. and Wyoming Medicaid data, and the National Survey of Children Health. Core interview questions were developed and framed to assess strengths, weaknesses (where MCH/Medicaid could assist), opportunities, and threats (barriers). 2. Complete qualitative data collection through interviews and surveys. Four core stakeholder groups were identified; healthcare providers, child-serving organizations, Medicaid leadership, and parents/caregivers. A total of twenty-one, on average one hour long, interviews were conducted. In addition, two healthcare provider surveys were completed with three respondents and one parent/caregiver survey was completed with seven respondents. 3. Complete thematic analysis of qualitative data. Stakeholder groups were divided in half among myself and my co-intern. Codes were developed using line-by-line coding and domains were developed based off similar codes. Both domains and codes were placed under their appropriate theme (priorities, strengths, weaknesses, opportunities, threats). Across stakeholder groups, frequency coding was collected to determine most commonly identified strengths, weaknesses, opportunities, and threats. 4. Identify existing resources and opportunities to support Bright Futures implementation. Through research and interviews, existing resources and opportunities were reviewed to determine how each could aid in guideline implementation.
2. Develop recommendations based off existing resources and qualitative analysis findings. Four recommendations were developed and reviewed with supervising team for feedback, edits, and approval. 6. Present recommendations for Bright Futures implementation to Wyoming Department of Health, MCH Unit and Wyoming Medicaid. Presented project process, findings, and recommendations to leadership using a PowerPoint presentation. The presentation was forty-five minutes followed by ten minutes of questions. An additional written document was provided detailing research methods, research findings, and preliminary recommendations for implementation with supporting resources.

Organization

Funded by the National MCH Workforce Development Center, I completed my field experience with the Wyoming Department of Health, Maternal and Child Unit Health. The Unit strives to provide “leadership to ensure Wyoming women, children and families, including those with special health care needs, have access to prevention services and public health programs” (WDH). The Unit is comprised of one manager, one administrative assistant, three program managers, and four coordinators. Developing recommendations for implementing Bright Futures was perfectly aligned with the Unit’s mission and overall goals as both the guidelines and Unit focus on populations from birth to age 21 and aim to ensure young people receive preventive care and screenings.

Findings from the qualitative analysis varied, however, common strengths, weaknesses, opportunities, and threats (barriers) were identified. Two primary strengths identified by stakeholders included coordinating care and educating families. Public Health Nurses were identified by other stakeholder groups as an entity that could coordinate care by following up with families and communicating with primary care providers in areas where relationships are established. Other child-serving organizations noted their capacity to follow up with families and coordinate care for them. Educating families was also identified as a strength. Providers and child-serving organizations have a direct route to families and indicated their abilities to educate and engage families in their health. Medicaid also noted this ability albeit on a smaller scale. Two areas identified where the MCH Unit and Medicaid could aid or provide guidance (weaknesses) included provider and family education. Providers indicated guidance needed to better educate and engage families on Bright Futures content, incorporating workflow tools, and identifying specialists they might refer patients to. Medicaid indicated training providers on how to code for visits in a way that captures EPSDT services and to educate providers on the reimbursements they’re missing out on because of how they’re coding. Topics that fell under educating families included advocating for well-visits in lieu/addition to sports physicals and having a tool that aide families in asking questions or discussing areas of health during a well-visit to promote self-advocacy and advocating for a family member. Leveraging schools and Public Health Nursing were opportunities to help implement and disseminate Bright Futures information. Trainings on coding as well as trainings for providers were also identified as opportunities. Finally, aligning electronic medical records (EMRs) with Bright Futures, which includes customizing and saving Bright Futures aligned templates or adopting a Bright Futures aligned EHR, was identified. Threats (barriers) among Medicaid, child-serving organizations, and provider stakeholders, identified two primary barriers; family education and provider education. Among providers, child-serving organizations, and parents/caregivers, access to care was identified and among Medicaid and providers, inaccurate coding was identified.

Lessons Learned

Through this field experience, I gained and enhanced several skills. At the end of the project, I better understood how units/divisions collaborate in efforts, enhanced my public speaking and interview skills, gained experience conducting a structured/semi-structured qualitative data analysis, collaborated with a co-intern, and delegated work to ensure project efficiency. Greater effort could have been made to reach stakeholders in rural communities. Additionally, due to timing, inter-reliability may have been compromised during the qualitative analysis stage.

Recommendations

Recommendations were provided in presentation and written form. Four core recommendations were developed and include; 1. Initiate the formation of a Bright Futures implementation task force to identify and carry out coordinated, sustainable, data-informed efforts to promote Bright Futures, 4th Edition in the state. 2. To better understand where services are either being missed or improperly coded, a Medicaid data request will be submitted and will include ICD-10 and CPT codes for each age group. This data request can be used to inform targeted coding guidance to practices. 3. To reach families, a public awareness campaign can be piloted in counties where primary care provider rates are the lowest. Suggestions for future efforts to target adolescents include presence at college/higher level of education school orientations, community outreach events, and education and awareness materials. Larger, age appropriate, SnapChat and Instagram messaging campaigns are recommended in order to reach the 12-21 age group. 4. The Wyoming Department of Health shall continue to work towards improved access to care for families, especially among rural communities and those with limited healthcare resources.

Conclusion 

The life-course development model explains that health trajectories are determined at a young age and develop and shift over formidable periods of a life. As a frontier state, Wyoming must continue to see opportunities for care coordination and health care access improvements in order to ensure young children and adolescents receive comprehensive health services.

References

1. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment. Retrieved from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html
2. U.S. News (2015). Well-visits for Medicaid Users Under 20. Retrieved from https://www.usnews.com/news/best-states/rankings
3. Wyoming Department of Health. Maternal and Child Health Unit. Retrieved from https://health.wyo.gov/publichealth/mch/